Background Small bowel obstruction (SBO) is a clinical condition that is often initially diagnosed and managed in the emergency department (ED). The high rates of potential complications that are associated with an SBO make it essential for the emergency physician (EP) to make a timely and accurate diagnosis. Objectives The primary objective was to perform a systematic review and meta-analysis of the history, physical examination, and imaging modalities associated with the diagnosis of SBO. The secondary objectives were to identify the prevalence of SBO in prospective ED-based studies of adult abdominal pain and to apply Pauker and Kassirer's threshold approach to clinical decision-making to the diagnosis and management of SBO. Methods MEDLINE, EMBASE, major emergency medicine (EM) textbooks, and the bibliographies of selected articles were scanned for studies that assessed one or more components of the history, physical examination, or diagnostic imaging modalities used for the diagnosis of SBO. The selected articles underwent a quality assessment by two of the authors using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Data used to compile sensitivities and specificities were obtained from these studies and a meta-analysis was performed on those that examined the same historical component, physical examination technique, or diagnostic test. Separate information on the prevalence and management of SBO was used in conjunction with the meta-analysis findings of computed tomography (CT) to determine the test and treatment threshold. Results The prevalence of SBO in the ED was determined to be approximately 2% of all patients who present with abdominal pain. Having a previous history of abdominal surgery, constipation, abnormal bowel sounds, and/or abdominal distention on examination were the best history and physical examination predictors of SBO. X-ray was determined to be the least useful imaging modality for the diagnosis of SBO, with a pooled positive likelihood ratio (+LR) of 1.64 (95% confidence interval [CI] = 1.07 to 2.52). On the other hand, CT and magnetic resonance imaging (MRI) were both quite accurate in diagnosing SBO with +LRs of 3.6 (5- to 10-mm slices, 95% CI = 2.3 to 5.4) and 6.77 (95% CI = 2.13 to 21.55), respectively. Although limited to only a select number of studies, the use of ultrasound (US) was determined to be superior to all other imaging modalities, with a +LR of 14.1 (95% CI = 3.57 to 55.66) and a negative likelihood ratio (–LR) of 0.13 (95% CI = 0.08 to 0.20) for formal scans and a +LR of 9.55 (95% CI = 2.16 to 42.21) and a –LR of 0.04 (95% CI = 0.01 to 0.13) for beside scans. Using the CT results of the meta-analysis for the 5- to 10-mm slice subgroup as well as information on intravenous (IV) contrast reactions and nasogastric (NG) intubation management, the pretest probability threshold for further testing was determined to be 1.5%, and the pretest probability threshold for beginning treatment was determined to be 20.7%. Conclusions The potentially useful aspects of the history and physical examination were limited to a history of abdominal surgery, constipation, and the clinical examination findings of abnormal bowel sounds and abdominal distention. CT, MRI, and US are all adequate imaging modalities to make the diagnosis of SBO. Bedside US, which can be performed by EPs, had very good diagnostic accuracy and has the potential to play a larger role in the ED diagnosis of SBO. More ED-focused research into this area will be necessary to bring about this change. Obstrucción de Intestino Delgado en el Adulto Introduction La obstrucción de intestino delgado (OID) es una situación clínica que a menudo es diagnosticada y manejada inicialmente en el servicio de urgencias (SU). El alto porcentaje de complicaciones potenciales que se asocian con la OID hace necesario que el urgenciólogo realice un diagnóstico certero de forma precoz. Objetivos El objetivo principal fue realizar una revisión sistématica y un metanálisis de la historia clínica, la exploración física y las modalidades de pruebas de imagen relacionadas con el diagnóstico de OID. Los objetivos secundarios fueron identificar la prevalencia de OID en los estudios prospectivos de adultos con dolor abdominal agudo en el SU, y aplicar la aproximación de Pauker and Kassirer a la toma de decisión clínica para el diagnóstico y el manejo de la OID. Metodología Se revisó MEDLINE, EMBASE, los principales libros de medicina de urgencias y emergencias y las bibliografías de los artículos seleccionados, que valoraron uno o más componentes de la historia, la exploración física y de las modalidades de pruebas de imagen utilizadas en el diagnóstico de la OID. Se llevó a cabo una valoración de la calidad de los artículos seleccionados mediante el Quality Assessment Tool for Diagnostic Accuracy Studies 2 (QUADAS-2). Los datos utilizados para compilar las sensibilidades y las especificidades se obtuvieron de estos estudios y se realizó un metanálisis en aquéllos que examinaron el mismo componente de la historia clínica, la exploración física, o la prueba diagnóstica. Una información diferente sobre la prevalencia y el manejo de la OID se utilizó junto con los hallazgos del metanálisis de la tomografía computarizada (TC) para determinar el umbral de la prueba diagnóstica y el tratamiento. Resultados La prevalencia de OID en el SU se determinó que era aproximadamente el 2% de todos los pacientes que presentan dolor abdominal agudo. Los mejores factores predictivos de OID en la historia clínica y la exploración física fueron el tener un antecedente previo de cirugía abdominal, el estreñimiento y/o la distensión abdominal en la exploración. La radiografía se determinó que era la modalidad de prueba de imagen de menor utilidad para el diagnóstico de OID, con un razón de probabilidad positiva (RP+) de 1,64 (IC 95% = 1,07 a 2,52). Por otro lado, la TC y la resonancia magnética nuclear (RMN) fueron ambas bastante certeras en el diagnóstico de OID, con una RP+ de 3,6 (cortes de 5 mm a 10 mm, IC 95% = 2,3 a 5,4) y 6,77 (IC 95% = 2,13 a 21,55), respectivamente. Aunque limitado a unos pocos estudios seleccionados, el uso de la ecografía (ECO) fue superior a todas las otras modalidades de estudios de imagen, con una RP+ de 14,1 (IC 95% = 3,57 a 55,66) y una razón de probabilidad negativa (RP-) de 0,13 (IC 95% = 0,08 a 0,20) para la evaluación estándar, y una RP+ de 9,55(IC 95% = 2,16 a 42,21) y una RP- de 0,04 (IC 95% = 0,01 a 0,13) para la evaluación a pie de cama. Usando los resultados del metanálisis de la TC para el subgrupo de 5 a 10 mm así como la información sobre las reacciones al contraste intravenoso y el manejo de la intubación nasogástrica, el umbral de la probabilidad pretest para las pruebas diagnósticas se determinó que era el 1,5%, y el umbral para la probailidad pretest para iniciar el tratamiento se estimó que era el 20,7%. Conclusiones Los aspectos potencialmente útiles de la historia clínica y la exploración física están limitados al antecedente de cirugía abdominal, el estreñimiento y el hallazgo en la exploración de distensión abdominal. La TC, la RMN y la ECO son todas modalidades de pruebas de imagen adecuadas para hacer el diagnóstico de OID. La ecografía a pie de cama, que puede ser realizada por los urgenciólogos, tuvo muy buena certeza diagnóstica y tiene potencial para jugar un destacado papel en el diagnóstico de OID en el SU. Será necesario investigar en el futuro en esta área en el SU para lograr este cambio.

Categoria: medicina | Fonte: academic emergency medicine

Objectives The objective was to evaluate the test characteristics of clinical examination (CE) with the addition of bedside emergency ultrasound (CE+EUS) compared to CE alone in determining skin and soft tissue infections (SSTIs) that require drainage in pediatric patients. Methods This was a prospective study of CE+EUS as a diagnostic test for the evaluation of patients 2 months to 19 years of age evaluated for SSTIs in a pediatric emergency department (ED). Two physicians clinically and independently evaluated each lesion, and the reliability of the CE for diagnosing lesions requiring drainage was calculated. Trained pediatric emergency physicians performed US following their CEs. The authors determined and compared the test characteristics for evaluating a SSTI requiring drainage for CE alone and for CE+EUS for those lesions in which the two physicians agreed and were certain regarding their CE diagnosis (clinically evident). The performance of CE+EUS was evaluated in those lesions in which the two physicians either disagreed or were uncertain of their diagnosis (not clinically evident). The reference standard for determining if a lesion required drainage was defined as pus expressed at the time of the ED visit or within 2 days by follow-up assessment. Results A total of 387 lesions underwent CE+EUS and were analyzed. CE agreement between physicians was fair (κ = 0.38). For the 228 lesions for which physicians agreed and were certain of their diagnoses, sensitivity was 94.7% for CE and 93.1% for CE+EUS (difference = –1.7%; 95% confidence interval [CI] = –3.4% to 0%). The specificity of CE was 84.2% compared to 81.4% for CE+EUS (difference = –2.8%; 95% CI = –9.7% to 4.1%). For lesions not clinically evident based on CE, the sensitivity of CE was 43.7%, compared with 77.6% for CE+EUS (difference = 33.9%; 95% CI = 1.2% to 66.6%). The specificity of CE for this group was 42.0%, compared with 61.3% for CE+EUS (difference = 19.3%; 95% CI = –13.8% to 52.4%). Conclusions For clinically evident lesions, the addition of ultrasound (US) did not significantly improve the already highly accurate CE for diagnosing lesions requiring drainage in this study population. However, there were many lesions that were not clinically evident, and in these cases, US may improve the accuracy of the CE. La Exploración Física junto a la Ecografía Urgente en las Infecciones de Piel y Partes Blandas en el Servicio de Urgencias Pediátrico Objetivos Evaluar las características diagnósticas de la exploración física (EF) junto con la ecografía urgente a pie de cama (EF+ECO) comparado con la EF únicamente en determinadas infecciones de piel y partes blandas (IPPB) que requieren drenaje en los pacientes pediátricos. Metodología Estudio prospectivo de EF+ECO como una prueba diagnóstica para la evaluación de pacientes de 2 meses a 19 años de edad atendidos por IPPB en un servicio de urgencias (SU) pediátrico. Dos médicos examinaron clínicamente y de forma independiente cada lesión y se calculó la fiabilidad de la EF para diagnosticar las lesiones que requieren drenaje. Los urgenciólogos pediátricos (UP) realizaron la echografía tras sus EF. Se determinó y comparó las características diagnósticas para evaluar si una IPPB requiere drenaje por la EF únicamente y por la EF+ECO para aquellas lesiones en que los dos UP estuvieron de acuerdo y estaban seguros sobre sus diagnósticos mediante la EF (clínicamente evidente). La realización de EF+ECO se evaluó en aquellas lesiones en las que los dos UP no estaban de acuerdo o no estaba seguros sobre sus diagnósticos (no clínicamente evidente). La referencia estándar para determinar si la lesión requería drenaje se definió como la salida de pus en el momento de la visita al SU o en los dos días siguientes a la visita. Resultados Se analizaron 387 lesiones en las que se realizó EF+ECO. La concordancia de la EF entre los médicos fue justa (K = 0,38). Para las 228 lesiones en las que los médicos estuvieron de acuerdo y seguros en sus diagnósticos, la sensibilidad fue del 94,7% para la EF y del 93,1% para la EF+ECO (diferencia –1,7%, IC95% = –3,4% a 0%). La especificidad para la EF fue del 84,2% comparado con el 81,4% para la EF+ECO (diferencia –2,8%, IC95% = –9,7% a 4,1%). Para las lesiones que no eran clínicamente evidentes basándose en la EF, la sensibilidad de la EF fue 43,7% comparado con el 77,6% para la EF+ECO (diferencia 33,9%, IC95% = 1,2% a 66,6%). La especificidad para la EF para este grupo fue del 42,0% comparado con el 61,3% para la EF+ECO (diferencia 19,3%, IC95% = –13,8% a 52,4%). Conclusiones Para las lesiones clínicamente evidentes, la adición de la echografía no mejoró significativamente la alta certeza de la EF para el diagnóstico de las lesiones que requieren drenaje en la población de estudio. Sin embargo, hubo muchas lesiones que no fueron clínicamente evidentes, y en estos casos la echografía puede mejorar la certeza de la EF.

Categoria: medicina | Fonte: academic emergency medicine

Introduction The h-index is an objective indicator of research productivity and influence on scholarly discourse within a discipline. It may be a valuable adjunct for measuring research productivity, a key component in decisions regarding appointment and promotion in academic medicine. The objectives of this analysis were to (1) examine whether there are gender disparities in research productivity among academic anaesthesiologists, and (2) compare results to measures of research productivity in other specialties. Methods A bibliometric analysis of faculty members from 25 academic anaesthesiology departments was performed using the Scopus database. Academic anaesthesiologists were organised by academic rank and gender. The h-index and publication range (in years) of faculty members were calculated. Results Male anaesthesiologists had higher research productivity, as measured by the h-index, than female colleagues. Organised by rank, this difference was noted only among full professors. Men had higher overall and early-career research productivity, while women had mid-career research productivity rates equivalent to and surpassing that of their male colleagues. Gender disparities in research productivity were also noted among a sample of academic physicians in other specialties. Conclusions While men had higher overall research productivity, women had equivalent or higher mid-career research output, suggesting that early-career considerations unique to women should be taken into account during appointment and promotion in academic anaesthesiology. While disparities in gender representation among anaesthesiologists have also been noted in Europe, further study as to whether these differences also extend to research productivity and academic promotion outside of the US would be of interest.

Categoria: medicina | Fonte: acta anaesthesiologica scandinavica

Background Endotracheal tubes (ETTs) are frequently used in paediatric anaesthesia. Correct placement is crucial. The aim of this study was to evaluate electrical impedance tomography (EIT) for guiding and confirmation of paediatric ETT placement. In a retrospective analysis of stored EIT data, distribution of ventilation between left and right lung was used to verify correct paediatric ETT placement. Methods Left and right lung ventilation was studied by EIT in 18 paediatric patients (median age: 53 months) requiring anaesthesia and endotracheal intubation. EIT was recorded before induction of anaesthesia, during mask ventilation, during ETT placement (including deliberate mainstem intubation), and after ETT repositioning according to the formula: ETT intubation depth (cm) = 3× ETT internal diameter (mm) or the mainstem intubation method (withdrawing the ETT 2 cm). Final ETT position was confirmed by fluoroscopy. Results Following deliberate mainstem intubation, distribution of ventilation to the right lung was unequivocally demonstrated by EIT. Homogeneous distribution of ventilation between left and right lung monitored with EIT correlated in each patient with correct endotracheal ETT placement. The distribution of left and right lung ventilation differed significantly (P < 0.05) between the initial two-lung ventilation and subsequent right one-lung ventilation, and between right one-lung and subsequent two-lung ventilation according to auscultation and the final ETT position, respectively. In one patient, ETT was misplaced within the oesophagus which was also obvious from the EIT record. Conclusion This study demonstrates that EIT enables non-invasive recognition of correct ETT placement. Homogeneous right-left-lung ventilation is an indicator for correct ETT placement.

Categoria: medicina | Fonte: acta anaesthesiologica scandinavica

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Categoria: biologia | Fonte: actionbioscience.org

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Categoria: biologia | Fonte: actionbioscience.org